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Non-antibiotic alternatives to preventing urinary tract infections

Diagnosis and management of UTIs and rUTIs

Current standard treatment of UTIs

Potential issues with antibiotic treatment

Antimicrobial stewardship

Other rUTI treatment options

GAG layer replacement

GAG layer replacement therapy

Your role in supporting patients with rUTIs

Assessment questions

module menu icon Your role in supporting patients with rUTIs

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module menu icon Your role in supporting patients with rUTIs

Your role in supporting patients with rUTIs

1Identify potential recurrent infections

Repeat purchases of OTC treatments for cystitis and repeat prescriptions for short courses of antibiotics may indicate potential rUTIs. You should have a conversation with these patients to provide practical recommendations regarding everyday management of symptoms and preventing recurrence, and refer them to their GP if necessary.

2Understand the impact of rUTIs on quality of life

rUTIs are associated with anxiety and depression due to treatment failures and symptomatic recurrences.7 Understanding the impact of UTIs and rUTIs on your patient’s quality of life is important in shaping your role in supporting them.

NICE recommends that women with recurrent lower UTIs where the underlying cause is unknown are referred for specialist advice.4,6 While these patients await their referral, you could share some coping strategies with them; for example, you could direct them to Antibiotic Research UK’s one-to-one patient support service at: www.antibioticresearch.org.uk/patient-support/

3Identify red flags

If symptoms worsen at any time, or do not start to improve within 48 hours of starting treatment, the patient should be reassessed.3,5

Those with persistent haematuria should be referred in line with NICE guidelines.9

Patients with the following signs and symptoms may have a kidney infection that could be serious if not treated:8

  • Have a high temperature, or feeling hot and shivery
  • Have a low temperature, or shaking and shivering
  • Have pain in the lower tummy or in the back, just under the ribs
  • Are confused, drowsy or have difficulty speaking
  • Are feeling or being sick
  • Have not had to urinate all day
  • Have blood in their urine that is different to that expected as part of the usual signs

Men and those under 16 years of age should also be referred.

References

1. NHS England. Delivery plan for recovering access to primary care. 2023. [Online.]
Available at: https://www.england.nhs.uk/long-read/delivery-plan-for-recovering-access-to-primary-care-2/

2. SIGN. 160. Management of suspected bacterial lower urinary tract infection in adult women. 2020. [Online.]
Available at: https://www.sign.ac.uk/media/1766/sign-160-uti-0-1_web-version.pdf

3. NICE. Urinary tract infection (lower): antimicrobial prescribing. 2018. [Online.]
Available at: https://www.nice.org.uk/guidance/ng109/resources/urinary-tract-infection-lower-antimicrobial-prescribing-pdf-66141546350533

4. NICE. Clinical Knowledge Summary. Urinary tract infection (lower) – women. 2023. [Online.]
Available at: https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/

5. BNF. Urinary tract infections. 2023. [Online.] Available at: https://bnf.nice.org.uk/treatment-summaries/urinary-tract-infections/

6. NICE. Urinary tract infections in adults. 2015, updated 2023. [Online.]
Available at: https://www.nice.org.uk/guidance/qs90/resources/urinary-tract-infections-in-adults-pdf-2098962322117

7. Cai T, et al. Recurrent UTI: questions and answers on clinical practice. Uro 2022; 2:262–269.

8. NHS. Cystitis. 2022. [Online.] Available at: https://www.nhs.uk/conditions/cystitis/

9. Rees et al. The diagnosis and management of uncomplicated recurrent urinary tract infection. 2018. [Online.]
Available at: https://img.medscapestatic.com/vim/live/professional_assets/20190911%20rUTI%20WPG%20v8%20FINAL.pdf

10. BNF. Drugs A to Z. 2023. [Online.] Available at: https://bnf.nice.org.uk/drugs/

11. Gov.UK. Nitrofurantoin: reminder of the risks of pulmonary and hepatic adverse drug reactions. 2023. [Online.]
Available at: https://www.gov.uk/drug-safety-update/nitrofurantoin-reminder-of-the-risks-of-pulmonary-and-hepatic-adverse-drug-reactions

12. NHS. Side effects of nitrofurantoin. 2022. [Online] Available at: https://www.nhs.uk/medicines/nitrofurantoin/side-effects-of-nitrofurantoin/

13. NHS. Trimethoprim. 2021. [Online.] Available at: https://www.nhs.uk/medicines/trimethoprim/

14. Antibiotic Research UK. 2021. [Online.] Available at: https://www.antibioticresearch.org.uk

15. Public Health England. Extended-spectrum beta-lactamases (ESBLs): FAQs. 2013. [Online.] Available at: https://www.gov.uk/government/publications/extended-spectrum-beta-lactamases-esbls-treatment-prevention-surveillance/extended-spectrum-beta-lactamases-esblsfaqs#what-illnesses-do-esbl-producing-e-coli-cause

16. Vachvanishsanong P et al. Extended-spectrum beta-lactamase Escherichia coli and Klebsiella pneumoniae urinary tract infections.
Epidemiology and Infection. 2020; 149( e12):1–7.

17. NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. 2015. [Online.]
Available at: https://www.nice.org.uk/guidance/ng15

18. Bladder Health UK. Intravesical medications. 2023. [Online.]
Available at: https://bladderhealthuk.org/interstitial-cystitis/icbps-treatments/intravesical-medications

19. Cicione A et al. Intravesical treatment with highly-concentrated hyaluronic acid and chondroitin sulfate in patients with recurrent urinary tract infections: results from a multicentre study. Can Urol Assoc J 2014; 8(9-10): E721-E727.

20. Khastgir, J. Intravesical GAG replacement therapies for bladder pain syndrome / interstitial cystitis – an update. 2020. [Online.]
Available at: https://www.urologynews.uk.com/features/features/post/intravesical-gag-replacement-therapies-for-bladder-pain-syndromeinterstitial-cystitis-an-update

21. Wyndaele J.J J. et al. GAG replenishment therapy for bladder pain syndrome/ interstitial cystitis. Neurourology and Urodynamics.
2018; 38:535-544.

22. Damiano R. et al. Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: a placebo-controlled randomised trial. Eur Urol. 2011; 59(4): 645-651.

23. De Vita D and Giordano S. Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study.
Int Urogynecol J 2012; 23(12): 1707-1713.

24. De Vita D and Giordano S. Long-term efficacy of intravesical instillation of hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis:
36 months’ follow-up. Clin.and Exp. Obstet. & Gynecol. – CEOG XLV n.2,2018.

25. Goddard JC and Janssen DA. Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: systematic review and metaanalysis. Int Urogynecol J. 2018; 29:933-942.

26. Gugliotta G et al. Is Intravesical instillation of hyaluronic acid and chondroitin sulfate useful in preventing recurrent bacterial cystitis?
A multicentre case control analysis. Taiwan J Obstet Gynecol 2015; 54(5):537-540.

27. Ciani O. et al. Intravesical administration of combined hyaluronic acid (HA) and chondroitin sulfate (CS) for the treatment of female recurrent urinary tract infections: a European multicentre nested case–control study. BMJ Open. 2016; 6:e009669.

Online references last accessed July 2023.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard